1
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Filosso PL, Guerrera F, Sandri A, Lausi PO, Lyberis P, Bora G, Roffinella M, Ruffini E. Surgical management of chronic diaphragmatic hernias. J Thorac Dis 2019; 11:S177-S185. [PMID: 30906583 DOI: 10.21037/jtd.2019.01.54] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chronic diaphragmatic hernia (CDH) is an uncommon disease which may be associated with significant morbidity and mortality. Antecedent (even many months or years before CDH development) blunt or penetrating thoracic/thoraco-abdominal trauma is generally recognized. A wide spectrum of different mechanisms of injury, timing in presentation, size of the diaphragmatic defect, types and amount of abdominal viscera herniated into the chest cavity, clinical symptoms are observed in CDHs. Thoracic and abdominal CT scan (with coronal, axial and sagittal reconstructions) is the best diagnostic tool; sometimes thoracic MRI is needed to better define the extent of the diaphragmatic defect and the number of abdominal organs displaced into the chest cavity. Surgery (sometimes urgent) represents the treatment of choice for CDH; diaphragmatic hernia direct repair with a tension-free suture is generally attempted; in case of very large defects or when a tension-free suture is deemed unfeasible, the use of prosthesis is recommended. This review article will discuss about CDH aetiology, clinical presentation diagnosis and surgical treatment.
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Affiliation(s)
- Pier Luigi Filosso
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Francesco Guerrera
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Alberto Sandri
- Unit of Thoracic Surgery, Department of Oncology, San Luigi Gonzaga Hospital, University of Torino, Torino, Italy
| | - Paolo Olivo Lausi
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Paraskevas Lyberis
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Giulia Bora
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Matteo Roffinella
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
| | - Enrico Ruffini
- Unit of Thoracic Surgery, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Torino, Torino, Italy
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Testini M, Girardi A, Isernia RM, De Palma A, Catalano G, Pezzolla A, Gurrado A. Emergency surgery due to diaphragmatic hernia: case series and review. World J Emerg Surg 2017; 12:23. [PMID: 28529538 PMCID: PMC5437542 DOI: 10.1186/s13017-017-0134-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/09/2017] [Indexed: 01/13/2023] Open
Abstract
Background Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17–6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations. Methods From May 2013 to June 2016, six cases (four females, two males; mean age 58 years) of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed. Results Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful. Conclusion Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality.
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Affiliation(s)
- Mario Testini
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School "Aldo Moro" of Bari, Bari, Italy
| | - Antonia Girardi
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School "Aldo Moro" of Bari, Bari, Italy
| | - Roberta Maria Isernia
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School "Aldo Moro" of Bari, Bari, Italy
| | - Angela De Palma
- Department of Thoracic Surgery, University of Bari, Bari, Italy
| | - Giovanni Catalano
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School "Aldo Moro" of Bari, Bari, Italy
| | - Angela Pezzolla
- Unit of Laparoscopic Surgery, Department of Emergency and Organ Transplantation, University Medical School "A. Moro" of Bari, Bari, Italy
| | - Angela Gurrado
- Unit of Endocrine, Digestive, and Emergency Surgery, Department of Biomedical Sciences and Human Oncology, University Medical School "Aldo Moro" of Bari, Bari, Italy
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3
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Siow SL, Wong CM, Hardin M, Sohail M. Successful laparoscopic management of combined traumatic diaphragmatic rupture and abdominal wall hernia: a case report. J Med Case Rep 2016; 10:11. [PMID: 26781191 PMCID: PMC4717597 DOI: 10.1186/s13256-015-0780-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 12/02/2015] [Indexed: 12/04/2022] Open
Abstract
Background Traumatic diaphragmatic rupture and traumatic abdominal wall hernia are two well-described but rare clinical entities associated with blunt thoracoabdominal injuries. To the best of our knowledge, the combination of these two clinical entities as a result of a motor vehicle accident has not been previously reported. Case presentation A 32-year-old Indian man was brought to our emergency department after being involved in a road traffic accident. He described a temporary loss of consciousness and had multiple tender bruises at his right upper anterior abdominal wall and left lumbar region. An initial examination revealed blood pressure of 99/63 mmHg, heart rate of 107 beats/minute, and oxygen saturation of 93 % on room air. His clinical parameters stabilized after initial resuscitation. A computed tomographic scan revealed a rupture of the left diaphragm as well as extensive disruptions of the left upper anterior abdominal wall. We performed exploratory laparoscopic surgery with the intention of primary repair. The diaphragmatic and abdominal wall defect was primarily closed, followed by reinforcement with PROLENE onlay mesh. The patient’s postoperative recovery was complicated by infected hematomas over both flanks that were managed with ultrasound-guided percutaneous drainage. He was discharged well despite a prolonged hospital stay. Conclusions We present a complex form of injuries managed successfully via a laparoscopic approach. Meticulous attention to potential complications in both the acute and convalescent phases is important for achieving a successful outcome following surgery.
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Affiliation(s)
- Sze Li Siow
- Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia. .,Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, 94300, Kota Samarahan, Sarawak, Malaysia.
| | - Chee Ming Wong
- Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia. .,Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, 94300, Kota Samarahan, Sarawak, Malaysia.
| | - Mark Hardin
- Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia.
| | - Mushtaq Sohail
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, 94300, Kota Samarahan, Sarawak, Malaysia.
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Kumar S, Pol M, Mishra B, Sagar S, Singhal M, Misra MC, Gupta A. Traumatic Diaphragmatic Injury: A Marker of Serious Injury Challenging Trauma Surgeons. Indian J Surg 2016; 77:666-9. [PMID: 26730084 DOI: 10.1007/s12262-013-0970-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 08/21/2013] [Indexed: 10/08/2023] Open
Abstract
The objectives of this study are (1) to evaluate prevalence of traumatic diaphragmatic injury (TDI), (2) identify the predictors of mortality, and (3) study the accuracy of investigations in survivors of TDI. Retrospective analysis of prospectively maintained database of TDI from January 2007 to December 2011. Emergency department (ED) records, operative details, and autopsy reports were reviewed to determine injury characteristics, treatment provided, and outcome. Statistical analyses were performed using the SPSS ver.15 software. TDI was identified in 75 individuals. Thirty-two of 75 (42.6 %) cases were brought dead to the hospital, and 43/75 (57.3 %) were survivors presented to emergency department, diagnosed to have TDI intraoperatively. Seven of 43 (16.3 %) died postoperatively. Mortality in TDI was significantly related to age (p = 0.001), injury severity (p < 0.001), site of TDI (p = 0.002), and associated injuries (p = 0.021, odds ratio of 9). Death increased with increase in the number of organ injured (p < 0.001, odds ratio of 12). Multi-detector computer tomography (MDCT) detected TDI in 23/26 (88.5 %) cases preoperatively. Laparotomy (p < 0.001, odds ratio of 22) and thoracotomy (p = 0.021, with odds ratio of 9) were associated with survival benefit when compared to minimal invasive surgery in injured cases. The prevalence of TDI was 2.67 %, TDI's mark severity of injury. Mortality increases with increasing number of organ injured. Right-sided or bilateral injury of diaphragm is associated with increased mortality.
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Affiliation(s)
- Subodh Kumar
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Manjunath Pol
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Biplab Mishra
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Singhal
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mahesh C Misra
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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5
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Özdemir M, Yanlı PY, Tomruk ŞG, Bakan N. Anaesthesia Management of a Patient with Incidentally Diagnosed Diaphragmatic Hernia During Laparoscopic Surgery. Turk J Anaesthesiol Reanim 2015; 43:50-4. [PMID: 27366465 DOI: 10.5152/tjar.2014.82787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 04/01/2014] [Indexed: 11/22/2022] Open
Abstract
Diaphragmatic hernia is usually congenital. However, it is rarely traumatic and can stay asymptomatic. In this report, we aimed to present the anaesthetic management of a patient with diaphragmatic hernia due to previous trauma (14 years ago), which was diagnosed incidentally during surgery for rectal cancer. The patient (53 years, 56 kg, 165 cm, American Society of Anaesthesiologist (ASA) II), to whom laparoscopic surgery was planned because of rectal cancer, had a history of falling from a height 14 years ago. Preoperatively, the patient did not have any sign except small right diaphragmatic elevation on the chest x-ray. After induction, maintenance of anaesthesia was continued with sevoflurane and O2/N2O. The patient was given a 30° Trendelenburg position. When the trochars were inserted by the surgeon, the diaphragmatic hernia was seen on the right part of the diaphragm, which was hidden by the liver. The surgery was continued laparoscopically but with low pressure (12 mmHg), because the patient did not have any haemodynamic and respiratory instability. The patient, who had stable haemodynamic parameters and no respiratory complications during the operation, was transferred to the ward for monitorised care. Traumatic diaphragmatic hernias can be detected incidentally after a long period of acute event. In our case, it was diagnosed during laparoscopic surgery. The surgery was completed with appropriate and careful haemodynamic monitoring and low intra-abdominal pressure under inhalational anaesthesia without any impairment in the patient's haemodynamic and respiratory parameters.
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Affiliation(s)
- Mehtap Özdemir
- Clinic of Anaesthesiology and Reanimation, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Pınar Yonca Yanlı
- Clinic of Anaesthesiology and Reanimation, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Şenay Göksu Tomruk
- Clinic of Anaesthesiology and Reanimation, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Nurten Bakan
- Clinic of Anaesthesiology and Reanimation, Ümraniye Training and Research Hospital, İstanbul, Turkey
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6
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Halvax P, Légner A, Paál B, Somogyi R, Ukös M, Altorjay A. [Laparoscopic reconstruction in traumatic rupture of the diaphragm]. Magy Seb 2014; 67:304-7. [PMID: 25327405 DOI: 10.1556/maseb.67.2014.5.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The authors report the case of a 63-year-old patient who was polytraumatized in a motor vehicle accident and suffered multiple traumatic injuries. Chest and pelvic fractures as well as left-sided diaphragmatic rupture with associated omentum herniation were diagnosed on CT scan. None of the injuries required urgent surgical intervention. After 10 days supportive therapy, elective laparoscopic reconstruction of the diaphragmatic hernia was performed. The authors discuss the role of laparoscopic diaphragm reconstruction.
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Affiliation(s)
- Péter Halvax
- Fejér Megyei Szent György Kórház Általános Sebészeti Osztály 8000 Székesfehérvár Seregélyesi út 3
| | - András Légner
- Fejér Megyei Szent György Kórház Általános Sebészeti Osztály 8000 Székesfehérvár Seregélyesi út 3
| | - Balázs Paál
- Fejér Megyei Szent György Kórház Általános Sebészeti Osztály 8000 Székesfehérvár Seregélyesi út 3
| | - Rózsa Somogyi
- Fejér Megyei Szent György Kórház Központi Aneszteziológia és Intenzív Betegellátó Osztály Székesfehérvár
| | - Mária Ukös
- Szent György Diagnosztikai Központ Székesfehérvár
| | - Aron Altorjay
- Fejér Megyei Szent György Kórház Általános Sebészeti Osztály 8000 Székesfehérvár Seregélyesi út 3
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7
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Diaphragmatic injuries: why do we struggle to detect them? Radiol Med 2014; 120:12-20. [DOI: 10.1007/s11547-014-0453-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 06/13/2014] [Indexed: 10/24/2022]
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8
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Abstract
The diagnosis of blunt diaphragmatic rupture (BDR) is difficult and often missed, leaving many patients with this traumatic injury at risk for life-threatening complications. The potential diagnostic pitfalls are numerous and include anatomic variants and congenital and acquired abnormalities. Chest radiography, despite its known limitations, may still be helpful in the early assessment of severe thoracoabdominal trauma and for detecting initially overlooked BDR or late complications of BDR. However, since the development of helical and multidetector scanners, computed tomography (CT) has become the reference standard; thus, knowledge of the CT signs suggestive of BDR is important for recognition of this injury pattern. A large number of CT signs of BDR have been described elsewhere, many of them individually, but the use of various appellations for the same sign can make previously published reports confusing. The systematic description and classification of CT signs provided in this article may help clarify matters and provide clues for diagnosing BDR. The authors describe 19 distinct CT signs grouped in three categories: direct signs of rupture, indirect signs that are consequences of rupture, and signs that are of uncertain origin. Since no single CT sign can be considered a marker leading to a correct diagnosis in every case of BDR, accurate diagnosis depends on the analysis of all signs present.
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Affiliation(s)
- Amandine Desir
- Department of Radiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
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9
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Kuo IM, Liao CH, Hsin MC, Kang SC, Wang SY, Ooyang CH, Fang JF. Blunt diaphragmatic rupture - a rare but challenging entity in thoracoabdominal trauma. Am J Emerg Med 2012; 30:919-24. [DOI: 10.1016/j.ajem.2011.03.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 03/24/2011] [Accepted: 03/25/2011] [Indexed: 12/23/2022] Open
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10
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Bocchini G, Guida F, Sica G, Codella U, Scaglione M. Diaphragmatic injuries after blunt trauma: are they still a challenge? Reviewing CT findings and integrated imaging. Emerg Radiol 2012; 19:225-35. [PMID: 22362421 DOI: 10.1007/s10140-012-1025-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 01/23/2012] [Indexed: 12/28/2022]
Abstract
Traumatic diaphragmatic rupture is a life-threatening injury that may occur in patients with blunt trauma. At present, supine chest radiographs is the initial, most commonly performed imaging test to evaluate a traumatic injury of the thorax. However, computed tomography (CT) is the imaging tool of choice, as it is the 'gold standard' for the detection of diaphragmatic injury after trauma. In particular, recent literature indicates that multidetector CT with multiplanar reformations has significantly improved in accuracy. Radiologists working in the emergency room should keep in mind the possibility of diaphragmatic injuries and should routinely integrate the axial images CT with multiplanar reformations in order to detect any potential, subtle or doubtful sign of incomplete diaphragmatic injury.
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Affiliation(s)
- Giorgio Bocchini
- Department of Diagnostic Imaging, Pineta Grande Medical Center, Via Domiziana Km. 30, Castel Volturno 81030, Italy
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11
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Baloyiannis I, Kouritas VK, Karagiannis K, Spyridakis M, Efthimiou M. Isolated right diaphragmatic rupture following blunt trauma. Gen Thorac Cardiovasc Surg 2011; 59:760-2. [PMID: 22083696 DOI: 10.1007/s11748-010-0759-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 12/06/2010] [Indexed: 11/25/2022]
Abstract
Blunt diaphragmatic injuries are usually caused by blunt trauma or penetrating injuries. The diagnosis may be delayed or missed because of the confusing clinical and radiographic findings and the presence of multiple associated injuries. We report the case of an isolated right diaphragm rupture in a 56-year-old man who sustained blunt thoracic trauma after car accident 2 weeks before presentation. No other injuries were detected, and he was subjected to laparotomy. Diaphragmatic rupture is perceived as an emergency entity. The late appearance of such an injury, without other accompanying injuries, is rare and should be in mind by clinicians treating trauma patients who have a delayed presentation after the injury.
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Affiliation(s)
- Ioannis Baloyiannis
- Department of Surgery, Larissa University Hospital, Mezourlo, 41 100, Larissa, Greece
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12
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Vilallonga R, Pastor V, Alvarez L, Charco R, Armengol M, Navarro S. Right-sided diaphragmatic rupture after blunt trauma. An unusual entity. World J Emerg Surg 2011; 6:3. [PMID: 21244704 PMCID: PMC3032671 DOI: 10.1186/1749-7922-6-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2010] [Accepted: 01/18/2011] [Indexed: 11/27/2022] Open
Abstract
Traumatic injuries of the diaphragm remain an entity of difficult diagnosis despite having been recognised early in the history of surgery, especially when it comes to blunt trauma and injuries of the right diaphragm. We report the case of a patient with blunt trauma with right diaphragmatic rupture that required urgent surgical treatment for hepatothorax and iatrogenic severe liver injury. Blunt trauma can cause substantial diaphragmatic rupture. It must have a high index of suspicion for diaphragmatic injury in patients, victims of vehicle collisions, mainly if they have suffered frontal impacts and/or side precipitates in patients with severe thoracoabdominal trauma. The diagnosis can be performed clinically and confirmation should be radiological. The general measures for the management of multiple trauma patients must be applied. Surgery at the time of diagnosis should restore continuity.
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Affiliation(s)
- Ramon Vilallonga
- General Surgery Department, Endocrine, bariatric and metabolic Unit, Universitary Hospital Vall d'Hebron, Autonomous University of Barcelona, Spain.
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13
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Hepatothorax: a rare outcome of high-speed trauma. Case Rep Emerg Med 2011; 2011:905641. [PMID: 23326700 PMCID: PMC3542917 DOI: 10.1155/2011/905641] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 09/13/2011] [Indexed: 11/18/2022] Open
Abstract
Diaphragmatic ruptures are the result of severe blunt trauma or penetrating trauma. Motor vehicle crashes are a common mechanism associated with blunt diaphragmatic rupture (BDR). Incorporating diagnostic tools and laparotomy assist in the diagnosis and treatment of BDR. However, diagnosing BDR can be a challenge for practitioners. Early diagnosis and treatment improve the patient's outcomes. This paper details the events of a patient received in a level I trauma unit.
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14
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Navallas M, Borruel S, Cano R, Ibáñez L. [Delayed diagnosis of a diaphragmatic hernia in a patient on mechanical ventilation]. RADIOLOGIA 2010; 52:552-5. [PMID: 20541784 DOI: 10.1016/j.rx.2010.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 03/25/2010] [Accepted: 04/14/2010] [Indexed: 10/19/2022]
Abstract
Traumatic rupture of the diaphragm is uncommon. Its early diagnosis is a challenge in diagnostic imaging. We present the case of a male multiple trauma patient in whom a left diaphragmatic hernia was discovered on weaning from mechanical ventilation 23 days after admission. We discuss the key imaging features of diaphragmatic rupture based on its physiopathology and thoracoabdominal pressure gradients. Very few cases of radiologically documented diaphragmatic hernias masked by mechanical ventilation have been reported.
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Affiliation(s)
- M Navallas
- Servicio de Radiología, Hospital 12 de Octubre, Madrid, España.
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15
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Parreira JG, Rasslan S, Utiyama EM. Controversies in the management of asymptomatic patients sustaining penetrating thoracoabdominal wounds. Clinics (Sao Paulo) 2008; 63:695-700. [PMID: 18925332 PMCID: PMC2664730 DOI: 10.1590/s1807-59322008000500020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Accepted: 06/12/2008] [Indexed: 11/21/2022] Open
Abstract
The most challenging diagnostic issue in the management of thoracoabdominal wounds concerns the assessment of asymptomatic patients. In almost one-third of such cases, diaphragmatic injuries are present even in the absence of any clear clinical signs. The sensitivity of noninvasive diagnostic tests is very low in this situation, and acceptable methods for diagnosis are limited to videolaparoscopy or videothoracoscopy. However, these procedures are performed under general anesthesia and present real, and potentially unnecessary, risks for the patient. On the other hand, diaphragmatic hernias, which can result from unsutured diaphragmatic lesions, are associated with considerable morbidity and mortality. In this paper, the management of asymptomatic patients sustaining wounds to the lower chest is discussed, with a focus on the diagnosis of diaphragmatic injuries and the necessity of suturing them.
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MESH Headings
- Diagnosis, Differential
- Hernia, Diaphragmatic, Traumatic/diagnosis
- Hernia, Diaphragmatic, Traumatic/etiology
- Hernia, Diaphragmatic, Traumatic/surgery
- Humans
- Sensitivity and Specificity
- Thoracic Injuries/diagnosis
- Thoracic Injuries/etiology
- Thoracic Injuries/surgery
- Thoracoscopy/methods
- Treatment Outcome
- Wounds, Penetrating/complications
- Wounds, Penetrating/diagnosis
- Wounds, Penetrating/surgery
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Affiliation(s)
- Jose Gustavo Parreira
- Division of Clinical Surgery III, Department of Surgery, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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16
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17
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Factors affecting mortality and morbidity after traumatic diaphragmatic injury. Surg Today 2007; 37:1042-6. [PMID: 18030563 DOI: 10.1007/s00595-007-3545-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2006] [Accepted: 02/20/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE We review our 11-year experience of treating diaphragmatic injury (DI), to identify the factors determining mortality and morbidity. METHODS We analyzed the effects of demographic characteristics, type of injury (blunt or penetrating), number of injured organs, injury severity score (ISS), revised trauma score (RTS), Glasgow coma score, and intensive care unit and hospital stay, on complications and mortality, in 51 patients treated for DI between January 1995 and December 2005. RESULTS Twenty-six (51%) patients suffered blunt injury and 25 (49%) suffered penetrating injury. The left diaphragm was injured in 40 (78%) patients, the right in 10 (19%), and both sides in 1 (2%). Only three (5.8%) patients had no concomitant injury. The diagnosis was made by the findings of laparotomy on 34 patients (65%), preoperative chest X-ray on 13 (25%), computed tomography on 2 (3.9%), and laparoscopy on 2 (3.9%). Complications developed in 23 (44%) patients and overall mortality was 19.6% (10/51). An ISS > 13 was found to be an independent prognostic factor for morbidity, whereas an RTS < or = 11, age > or = 48 years, and a major postoperative complication were independent prognostic factors for mortality. CONCLUSION Establishing a preoperative diagnosis of DI is still problematic. Aggressive treatment and close monitoring of patients with an ISS > 13, an RTS < or = 11, an age > or = 48 years, or a postoperative complication may decrease morbidity and mortality.
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18
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McGillicuddy D, Rosen P. Diagnostic Dilemmas and Current Controversies in Blunt Chest Trauma. Emerg Med Clin North Am 2007; 25:695-711, viii-ix. [PMID: 17826213 DOI: 10.1016/j.emc.2007.06.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Blunt chest injuries are common encounters in the emergency department. Instead of a comprehensive review of the management of all chest injuries, this review focuses on injuries that can be difficult to diagnose and manage, including blunt aortic injury, cardiac contusion, and blunt diaphragmatic injury. This review also discusses some recent controversies in the literature regarding the use of prophylactic antibiotics for tube thoracostomy and the optimal management of occult pneumothorax. The article concludes with a discussion of the management of rib fractures in the elderly.
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Affiliation(s)
- Daniel McGillicuddy
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, One Deaconess Road, W/CC-2, Boston, MA 02215, USA.
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Kuzucu A, Işık B, Baysal T, Soysal Ö, Ulutaş H. Traumatic intrapericardial diaphragmatic hernia. Radiography (Lond) 2007. [DOI: 10.1016/j.radi.2006.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
PURPOSE Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury. METHODS Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine. RESULTS Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this. DISCUSSION Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.
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Affiliation(s)
- G Matthes
- Ernst-Moritz-Arndt-Universität Greifswald, Unfall- und Wiederherstellungschirurgie, Sauerbruchstrasse, 17475 Greifswald.
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Genotelle N, Lherm T, Gontier O, Le Gall C, Caen D. Hémothorax droit intarissable révélateur d'une plaie hépatique avec rupture diaphragmatique. ACTA ACUST UNITED AC 2004; 23:831-4. [PMID: 15345257 DOI: 10.1016/j.annfar.2004.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2004] [Accepted: 05/25/2004] [Indexed: 11/22/2022]
Abstract
We report a case of a woman with a blunt thoracic trauma and haemorrhagic shock after a road traffic accident. The clinical and complementary examinations revealed an isolated right haemothorax, which was compressive and uncontrollable. The source of bleeding was discovered with delay and during a surgical exploration: it was a liver injury with diaphragmatic rupture but without hepatic herniation and peritoneal effusion. The diagnostic features of blunt diaphragmatic rupture are discussed.
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Affiliation(s)
- N Genotelle
- Service de réanimation polyvalente, hôpital Gilles-de-Corbeil, centre hospitalier Sud-Francilien, 59, boulevard Henri-Dunant, 91106 Corbeil-Essonnes cedex, France
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